Psychotherapy: Short-term models
Cognitive-behavioural therapy (CBT)
- A here-and-now therapeutic collaboration that examines assumptions and beliefs, and challenges and tests them
- Based on a cognitive model, where thoughts and behaviour determine emotional reactions to stressful life events
- Structured, with an agenda set and followed in each session
- Goal-oriented, with behavioural goals delineated and measured throughout therapy
- Time-limited, typically 12 sessions for anxiety and 16–20 sessions for depression
- Based on a teaching model, where patients learn the skills to become their own therapist
- Includes homework assignments to enhance skill acquisition, often using self-help manuals
- Teaches relapse prevention
Interpersonal therapy (IPT)
- Based on psychodynamic and interpersonal models, which connect psychological problems to communication problems rooted in insecure attachment styles and early life experiences
- Recognizes genetic, neurobiological, developmental and personality factors as predisposing and precipitating factors for depression
- Views depression as a medical illness that occurs within a social context. Interpersonal issues are linked to depressed mood and depression impairs interpersonal functioning.
- Focuses on interpersonal factors that perpetuate depression
- Assesses patient's past history in a detailed manner
- Helps patients to communicate their interpersonal needs and emotions more effectively
- Provides comprehensive psychoeducation about depression, including ways that the patient has adopted the "sick role" of depression
- Identifies one or two focal areas for time-limited therapeutic work, such as interpersonal disputes, role transitions, bereavement and interpersonal deficits
- Typically involves 16 weekly sessions
Solution-focused therapy (SFT)
- Pragmatic, active therapy that emphasizes a specific therapeutic style or stance rather than specific techniques and theories of psychopathology
- Based on social constructionist philosophy
- More creative and flexible and less manualized than CBT and IPT
- Style can be integrated into CBT and IPT
- Focuses on what the patient wants to achieve through therapy rather than on the problems that made the person seek help
- Does not focus on the past but on the present and future
- Encourages the patient to create a concrete vision of a "preferred future" and then pay attention to movement toward this vision
- Focuses on the patient's "personal story," strengths and resources
- Examines exceptions to the patient's problem (when the problems are not as severe)
Committing time for psychotherapy
Long-term psychotherapy, although commonly practised in the community, is not recommended for patients with currently active mood or anxiety disorders.
CBT, IPT and SFT require the clinician to be very comfortable using general supportive psychotherapy techniques such as active listening, empathy, warmth and genuineness. With CBT, IPT and SFT, the clinician also initially needs to allocate a regular time to meet with the patient, rather than scheduling sessions as needed.
The sessions do not need to run the typical 45–50 minutes, but at least 15–30 minutes once a week is necessary to develop a rapport with the patient and create sufficient momentum to achieve therapeutic success.
What form of psychotherapy works best in primary care?
- There are few overall efficacy differences between CBT and IPT for mild to moderate depression.
- CBT is the most comprehensively studied psychotherapy and is the first choice for anxiety disorders. There is currently only weak evidence for the efficacy of IPT in anxiety disorders.
- CBT may be used alone for anxiety disorders, particularly if the condition is mild.
- CBT has a broad spectrum of action beyond mood and anxiety disorders. For example, CBT has been successful in treating eating disorders, substance use problems, chronic fatigue, sexual dysfunction and anger control.
- SFT has not been studied as systematically as CBT, but appears to be effective in treating mild depression.
- CBT has some advantages over IPT: The therapist requires less psychotherapy experience, the structure is beneficial for more symptomatic patients and extensive supplementary self-help bibliotherapy is available, such as Mind Over Mood or the The Feeling Good Handbook.
- IPT has some advantages over CBT: It places less emphasis on formal homework, writing and language skills and structure, and there is evidence of efficacy in non-Western populations and patients from lower socioeconomic backgrounds.
Integrating psychotherapy in primary care
The recommended approach for primary care providers doing psychotherapy is to integrate strategies from CBT, IPT and SFT. This "modified CBT-lite" approach has various features:
- takes a pragmatic, highly active and supportive approach
- emphasizes addressing one or two core problems in the here and now
- leverages and reinforces the patient's inner strengths to achieve change
- creates momentum by adopting a therapeutically optimistic stance, refraining from excessive focus on the patient's past or psychopathology
- involves psychoeducation about mental illness, usually including family members
- includes bibliotherapy and self-help exercises